Focusing on Doctor-Patient Communication with Older Adults

Adapted from a presentation to the HSS Rheumatology Division, Monday, November 12, 2007

Juliette KleinmanVOICES 60+ Program Manager, Hospital for Special Surgery

The mission of the VOICES 60+ Program at HSS is to enhance the medical care experience of low income, ethnically diverse older adults that come to HSS for the treatment of their rheumatologic and orthopedic conditions. A major strategy for accomplishing this is focusing on communication between our patients and their doctors.

Research has shown that the quality of doctor-patient communication is critical to health care outcomes and medical adherence. This can be especially challenging in the context of treating older adult patients. For example, in a review article by Michelle Greene and Ronald Adelman regarding physician and older patient communication about psychosocial issues, they identified several barriers to effective doctor patient relationships. Their review highlights the following findings:

Doctors spend less time on psychosocial issues with older adult patients during the medical encounter and are less likely to raise these concerns.

Older adults receive less health education and counseling than younger patients, with doctors spending more time checking on compliance with treatment and developing treatment plans.

Older adult patients ask fewer questions and defer to the physician’s authority than do younger patients.

This potential disconnect between older adult patients and their doctors can be further confounded by a sense of shame and embarrassment by the patient around issues of vulnerability and loss of control. These feelings can prevent older adult patients from sharing vitally important issues with their physicians that will impact treatment adherence and health outcomes. For example, in our own interviews with 19 Rheumatology ACC patients, four of them expressed as a major health concern a fear of falling, and yet none had discussed this with their HSS physicians.

This scenario is further complicated by challenges in health literacy. Health literacy - the ability to read, understand, and effectively use basic medical instructions and information - is the strongest predictor of an individual’s health status. While low health literacy can affect anyone of any age, ethnicity, background, and education level, populations that are disproportionately vulnerable to low health literacy include:

Older patients

Recent immigrants, who may be highly literate in their native language

People with chronic disease

Those with low socio-economic status

In fact, the majority of our patients seen in Rheumatology ACC mirror these characteristics. Furthermore, a study recently published in The Journal of Rheumatology comprised of 80 patients with rheumatoid arthritis found that a significant number of patients with RA had limited health literacy. Their scores on three literacy tests indicated that they may not understand even simple written instructions or prescription labels. These issues, therefore, are very relevant and present important implications for the care of our own patients.

Many strategies have been explored to address both enhancing doctor-patient communication and improving health literacy. These strategies have been directed toward the patient or physician, or both. A strategy VOICES 60+ has implemented involves patient coaching; that is, helping patients to think of the questions they want to ask, along with a “Tip Sheet” that includes question prompts.

A meta-analysis of these kinds of patient-focused interventions was recently published by The Cochrane Collaboration. The analysis involved 33 randomized controlled trials with over 8000 patients in a range of clinical settings. The review studied interventions before healthcare consultations to help patients get the information they require. The team of researchers found statistically significant results which demonstrated that patients who received these interventions just prior to their doctors’ visits asked more questions, were more satisfied with their medical care, and had less anxiety.

Most interventions (which included written materials, such as “question prompt sheets” and coaching sessions) were delivered in the waiting room immediately before the consultation. Studies of older adults continue to demonstrate that patients who play a more active role in the physician encounter, who come with questions, relevant medical history, and current medications, for example, are more likely to adhere to recommended treatment - a critical component of patient self-management.

Therefore, based on the literature, our program mission, and our clinical experience, VOICES 60+ has created its own “Tip Sheet” for patients as part of a pre-appointment coaching intervention. The “Tip Sheet” is adapted from a publication of The National Institute on Aging and The Partnership for Clear Health Communication. The goal of the “Tip Sheet” is to provide patients with the tools and skills that will create optimal doctor-patient partnerships and positive health outcomes for our older adult patients.